NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?
Correct Answer: B
Rationale: Placing the infant on her abdomen may allow for injury to the suture line. Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. The suture line is cleaned as often as every hour to prevent crusting and scarring. Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring.
Question 2 of 5
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:
Correct Answer: C
Rationale: A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.
Question 3 of 5
The nurse is caring for a client with a history of cirrhosis. The nurse should give priority to:
Correct Answer: A
Rationale: Cirrhosis impairs clotting factor production, increasing bleeding risk, so monitoring for bleeding is a priority.
Question 4 of 5
The nurse caring for a client with closed chest drainage notes that the collection chamber is full.
Correct Answer: D
Rationale: A full collection chamber requires replacing the chest drainage unit to maintain effective drainage and prevent complications like tension pneumothorax.
Question 5 of 5
A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for what additional correlating wedge pressure data?
Correct Answer: B
Rationale: PAWP of 14 mmHg is elevated, suggesting left ventricular overload. Rales (
B) indicate pulmonary edema, correlating with high PAWP. BP drop (
A), fever (
C), and dry membranes (
D) are unrelated.